Note: This is an update to the September 2016 Medicaid Ordering, Prescribing or Referring (OPR) Special Bulletin. The 2016 OPR Special Bulletin should no longer be used as reference.
This bulletin applies to NC Medicaid Managed Care and NC Medicaid Direct.
According to Federal regulation 42 CFR 42 455.410, any physician or other practitioner who orders, prescribes, refers or renders services to a North Carolina Medicaid beneficiary must be enrolled in the North Carolina Medicaid program.
Federal regulation requires the NPI of any ordering or referring physician or other professional to be specified on any claim for payment. To be reimbursed for services or supplies resulting from a practitioner's order, prescription, or referral, the ordering, prescribing, or referring provider must be enrolled in NC Medicaid.
Note: A streamlined application for Ordering, Rendering and Referring providers is available through NCTracks.
Ordering Provider NPI is required on the following types of claims:
- Home Infusion Therapy (HIT)
- Independent Diagnostic Treatment Facilities (IDTF)/Portable X-ray*
- Private Duty Nursing (PDN)
- Independent Labs/X-ray*
- Community Alternatives Program (CAP) Services
- Immunizing Pharmacist
- Radiology Procedures*
- Durable Medical Equipment (DME)
- Children’s Development Service Agencies (CDSA)
Except when billed with following codes:
| Procedure Code | Modifier | Description |
|---|---|---|
| H0031 | MENTAL HEALTH ASSESSMENT, BY NON-PHYSICIAN | |
| H0036 | COMMUNITY PSYCHIATRIC SUPPORTIVE TREATMENT, FACE-TO-FACE, PER 15 MINUTES | |
| H0036 | HI | COMMUNITY BASED SERVICES EARLY CHILDREN INTERVENTION PROFESSION IND 15 MINS |
| H0036 | HM | COMMUNITY BASED SERVICES PARAPROFESSIONAL INDIVIDUAL 15 MINUTES |
| H0036 | HQ | COMMUNITY BASED SERVICES PROFESSIONAL GROUP 2 CLIENTS 15 MINUTES |
| H0036 | TL | COMMUNITY BASED SERVICES - PROFESSIONAL 2 CLIENTS 15 MINUTES |
| T1017 | HI | TARGET CASE MANAGEMENT - EARLY INTERVENTION |
| T1023 | SCREENING TO DETERMINE THE APPROPRIATENESS OF CONSIDERATION OF AN INDIVIDUAL |
*Exception: Ordering NPI is not required when billing only the professional component (modifier 26).
Referring provider NPI is required on the following types of claims:
- Home Infusion Therapy (HIT)
- Specialized Therapy – Outpatient and Independent Practitioners
- Hospice
- Home Health
- Private Duty Nursing (PDN)
- Outpatient Hospital Clinics – Dialysis Facilities
- Community Alternatives Program (CAP) Services
Additional Requirements
Both the Ordering and Referring NPI submitted on the claim must be an individual, not an organization or group.
Operating Provider NPI is required when an operating room revenue code is submitted.
Service facility NPI is required on Hospice claims when the member resides in a Nursing Facility.
If services are furnished to beneficiaries in another state, the out-of-state providers are required to enroll with NC Medicaid. Enrollment in another state’s Medicaid program does not exempt a rendering, ordering, prescribing or referring provider from enrolling with NC Medicaid.
Billing providers should verify the enrollment of the individual rendering, ordering, prescribing or referring provider before services are rendered. The “Enrolled Practitioner Search” function is available on NCTracks provider portal for this purpose. This feature allows providers to inquire about other providers enrolled in NC Medicaid. Additionally, the Enrolled Practitioner Search provides the capability to validate provider information for billing, attending, referring, rendering, ordering, and prescribing providers.
Contact
NCTracks Call Center: 800-688-6696